Healthcare Provider Details

I. General information

NPI: 1598733164
Provider Name (Legal Business Name): CARMELA REYNOSO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 04/01/2024
Certification Date: 04/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35325 DATE PALM DR STE 131
CATHEDRAL CITY CA
92234-7031
US

IV. Provider business mailing address

408 HIGUERA ST STE 200
SAN LUIS OBISPO CA
93401-6135
US

V. Phone/Fax

Practice location:
  • Phone: 760-202-0368
  • Fax: 760-770-1973
Mailing address:
  • Phone: 805-788-0805
  • Fax: 805-788-0845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT32508
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: